Developing the Active Communities Tool to Implement the Community Guide's Built Environment Recommendation for Increasing Physical Activity.

Physical activity is higher in communities that include supportive features for walking and bicycling. In 2016, the Community Preventive Services Task Force released a systematic review of built environment approaches to increase physical activity. The results of the review recommended approaches that combine interventions to improve pedestrian and bicycle transportation systems with land use and environmental design strategies. Because the recommendation was multifaceted, the Centers for Disease Control and Prevention determined that communities could benefit from an assessment tool to address the breadth of the Task Force recommendations. The purpose of this article is to describe the systematic approach used to develop the Active Communities Tool. First, we created and refined a logic model and community theory of change for tool development. Second, we reviewed existing community-based tools and abstracted key elements (item domains, advantages, disadvantages, updates, costs, permissions to use, and psychometrics) from 42 tools. The review indicated that no tool encompassed the breadth of the Community Guide recommendations for communities. Third, we developed a new tool and pilot tested its use with 9 diverse teams with public health and planning expertise. Final revisions followed from pilot team and expert input. The Active Communities Tool comprises 6 modules addressing all 8 interventions recommended by the Task Force. The tool is designed to help cross-sector teams create an action plan for improving community built environments that promote physical activity and may help to monitor progress toward achieving community conditions known to promote physical activity.

The Association between Neighborhood Environments and Physical Activity from Pregnancy to Postpartum: a Prospective Cohort Study.

The objectives of this study were to determine if neighborhood measures were associated with physical activity cross-sectionally during late pregnancy (27-30 weeks' gestation), 3 months postpartum, and 12 months postpartum, and longitudinally with an increase in physical activity from late pregnancy to 12 months postpartum. Data are from the Pregnancy, Infection, and Nutrition (PIN3) and Postpartum Prospective Cohort Study. Dichotomized self-reported recreation and total physical activity hours/week were explored cross-sectionally at three time points, and as an increase over time. Four factors from a neighborhood environmental audit were examined: arterial or thoroughfare, walkable neighborhood, physical incivilities, and decoration. Secondary spatial data included population density, hilliness, intersection density, distance to nearest major road, distance to nearest park, distance to nearest physical activity facility, and distance to nearest bus stop. Multilevel mixed-effects logistic regression models were used to assess the association between environmental variables and physical activity measures. A number of environmental variables were associated with total and recreation physical activity at the three time points in cross-sectional models. For increase in recreation physical activity over time, a moderate distance to nearest major road was significantly associated with increased recreation physical activity from 3 to 12 months postpartum (tertile 2 OR 2.13, 95% CI 1.08, 4.22). Living the furthest distance from the nearest park was inversely associated with an increase in recreation physical activity from pregnancy to 3 months postpartum (tertile 3 OR 0.50, 95% CI 0.29, 0.85). The findings of this study indicate that several aspects of the neighborhood environment, such as walkability, access to transit, distance to recreation facilities, and road networks, are associated with physical activity during different stages of pregnancy and postpartum. Since physical activity may result in long-term health benefits for both the woman and child, environments that support this activity should be encouraged.

Reliability and One-Year Stability of the PIN3 Neighborhood Environmental Audit in Urban and Rural Neighborhoods.

Reliable and stable environmental audit instruments are needed to successfully identify the physical and social attributes that may influence physical activity. This study described the reliability and stability of the PIN3 environmental audit instrument in both urban and rural neighborhoods. Four randomly sampled road segments in and around a one-quarter mile buffer of participants' residences from the Pregnancy, Infection, and Nutrition (PIN3) study were rated twice, approximately 2 weeks apart. One year later, 253 of the year 1 sampled roads were re-audited. The instrument included 43 measures that resulted in 73 item scores for calculation of percent overall agreement, kappa statistics, and log-linear models. For same-day reliability, 81% of items had moderate to outstanding kappa statistics (kappas ≥ 0.4). Two-week reliability was slightly lower, with 77% of items having moderate to outstanding agreement using kappa statistics. One-year stability had 68% of items showing moderate to outstanding agreement using kappa statistics. The reliability of the audit measures was largely consistent when comparing urban to rural locations, with only 8% of items exhibiting significant differences (α < 0.05) by urbanicity. The PIN3 instrument is a reliable and stable audit tool for studies assessing neighborhood attributes in urban and rural environments.

Perceived Social and Built Environment Correlates of Transportation and Recreation-Only Bicycling Among Adults.

INTRODUCTION: Research on perceptions of environmental factors in relation to transportation and recreation bicycling is limited in the United States. We explored the association between perceived social and built environment factors with total, transportation, and recreation bicycling in a sample of adult bicyclists in Austin, Texas, and Birmingham, Alabama. The objective of this study was to examine the relationship between perceived social and built environment factors and domain-specific bicycling in a sample of adult bicyclists. METHODS: Adults aged 18 to 65 who rode a bicycle at least once in the past year completed an internet-based survey that was developed for this study to specifically assess correlates of bicycling; the study was conducted from October 2016 through January 2017. Perceived environmental factors assessed were residential density, traffic safety, destination, connectivity, safety from crime, aesthetics, and bicycle infrastructure. Multivariable logistic regression models were used to estimate the association of each perceived environmental factor (tertile 1, lowest; tertile 3, highest) with recreation-only and transportation bicycling. Effect modification of the relation between environmental factors and bicycling outcomes by sex was also examined. RESULTS: The final analytic sample size was 801 participants. All environmental factors examined, including residential density, traffic safety, destinations, connectivity, aesthetics, bicycle infrastructure, and safety from crime showed significantly direct associations with transportation bicycling. Traffic safety, destinations, aesthetics, and bicycle infrastructure showed significant direct and inverse associations with recreation-only bicycling. Effect modification by sex was identified with residential density; a significant direct association with recreation-only bicycling was seen among women. CONCLUSION: These findings illustrate that bicycling for transportation is associated with different perceived environmental factors than is recreation-only bicycling, with some significant modification by sex. Comprehensive tools that assess the perceived environment for bikeability in the United States are warranted.

Occurrence of COVID-19 and serum per- and polyfluoroalkyl substances: A case-control study among workers with a wide range of exposures.

Per- and polyfluoroalkyl substances (PFAS) are a broad class of synthetic chemicals; some are present in most humans in developed countries. Some studies suggest that certain PFAS may have immunotoxic effects in humans, which could put individuals with high levels of exposure at increased risk for infectious diseases such as COVID-19. We conducted a case-control study to examine the association between COVID-19 diagnosis and PFAS serum concentrations among employees and retirees from two 3 M facilities, one of which historically generated perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), and perfluorohexane sulfonic acid (PFHxS). Participants completed enrollment and follow-up study visits in the Spring of 2021. Participants were categorized as cases if they reported a COVID-19 diagnosis or became sick with at least one symptom of COVID-19 when someone else in their household was diagnosed, otherwise they were categorized as a control. COVID-19 diagnosis was modeled in relation to concentration of serum PFAS measured at enrollment after adjusting for covariates. The analytic sample comprised 573 individuals, 111 cases (19.4%) and 462 controls (80.6%). In adjusted models, the odds ratio of COVID-19 was 0.94 per interquartile range (14.3 ng/mL) increase in PFOS (95% confidence interval 0.85, 1.04). Results for PFOA, PFHxS, and perfluorononanoic acid (PFNA) were similar. Other PFAS present at lower concentrations were examined as categorical variables (above the limit of quantification [LOQ], yes vs. no [referent category]), and also showed no positive associations. In our study, which used individual-level data and included people with high occupational exposure, the serum concentrations of all PFAS examined were not associated with an increased odds ratio for COVID-19. At this point, the epidemiologic data supporting no association of COVID-19 occurrence with PFAS exposure are stronger than those suggesting a positive association.

Validity, Reliability, and Usability of a Smartphone App to Measure Bicycling Location.

This study evaluates concurrent validity, test-retest reliability, and usability of the Strava smartphone app for measuring bicycling locations in urban and rural field tests. Strava location data were inside an 11-meter buffer on average 64% of the time compared to Qstarz' 52%, over 100 evaluations (n participants=73). Most participants agreed or strongly agreed that the Strava app was useful (83%) and that they would prefer to use a smartphone app to track their bicycling (42%). Results indicate that the Strava app is reliable and valid for measuring bicycling locations in these field tests.

Burnout in and Commission of Medical Errors by Secondary School Athletic Trainers.

CONTEXT: Commission of medical errors by health care providers can be costly and potentially fatal for their patients. Previous researchers found a correlation between burnout and the commission of medical errors by physicians. The Smith Cognitive-Affective Model of Athletic Burnout suggests that emotional exhaustion and decreased personal accomplishment in athletic trainers (ATs) may be associated with behavioral outcomes such as commission of medical errors, but this association has not been examined. OBJECTIVE: To explore the association between burnout in and commission of medical errors by ATs. DESIGN: Cross-sectional study. SETTING: Web-based survey. PATIENTS OR OTHER PARTICIPANTS: A total of 403 certified ATs working in the secondary school setting were recruited via multiple social media pages and the National Athletic Trainers' Association Research Survey Service. MAIN OUTCOME MEASURE(S): An online questionnaire that consisted of 97 items from previously used scales was distributed to participants. A logistic regression model with personal accomplishment and emotional exhaustion as independent variables and a dichotomous variable for commission of medical errors (yes or no) as a dependent variable was calculated. A Poisson regression model with personal accomplishment and emotional exhaustion as independent variables and number of medical errors committed as a dependent variable was also calculated. RESULTS: Approximately 18.4% of our sample admitted to committing at least 1 medical error in the last 30 days. Both personal accomplishment (odds ratio = 1.06, P = .005) and emotional exhaustion (odds ratio = 1.02, P = .037) were significantly associated with commission of at least 1 medical error. Emotional exhaustion (B = .02, P = .002) was significantly associated with the number of medical errors committed. CONCLUSIONS: Athletic trainers committed medical errors at a rate comparable with that of other health care professionals. Burnout was directly associated with both the likelihood of an AT committing a medical error and the number of errors an AT committed.

Antibody response to COVID-19 vaccines among workers with a wide range of exposure to per- and polyfluoroalkyl substances.

Per- and polyfluoroalkyl substances (PFAS) are a broad class of synthetic chemicals; some are present in most humans in developed countries. Several studies have shown associations between certain PFAS, such as perfluorooctanoic acid (PFOA) and perfluorooctane sulfonic acid (PFOS), and reduced antibody concentration after vaccination against diseases such as Tetanus. Recent studies have reported associations between COVID-19 occurrence and exposure to certain types of PFAS. However, studies of antibody concentration after COVID-19 vaccination in relation to PFAS serum concentrations have not been reported. We examined COVID-19 antibody responses to vaccines and PFAS serum concentrations among employees and retirees from two 3M facilities, one of which historically manufactured PFOS, PFOA, and perfluorohexane sulfonic acid (PFHxS). Participants completed enrollment and follow-up study visits in the Spring of 2021, when vaccines were widely available. In total 415 participants with 757 observations were included in repeated measures analyses. Log-transformed concentrations of anti-spike IgG and neutralizing antibodies were modeled in relation to concentration of PFAS at enrollment after adjusting for antigenic stimulus group (9 groups determined by COVID-19 history and number and type of vaccination) and other variables. The fully adjusted IgG concentration was 3.45 percent lower (95% CI -7.03, 0.26) per 14.5 ng/mL (interquartile range) increase in PFOS; results for neutralizing antibody and PFOS were similar. For PFOA, PFHxS, and perfluorononanoic acid (PFNA), the results were comparable to those for PFOS, though of smaller magnitude. In our study data, the fully adjusted coefficients relating concentration of vaccine-induced antibodies to COVID-19 and interquartile range difference in serum concentration of PFOS, PFOA, PFHxS, and PFNA were inverse but small with confidence intervals that included zero. Our analysis showed that the coefficient for the four PFAS examined in detail was considerably affected by adjustment for antigenic stimulus group.

Participation in specific leisure-time activities and mortality risk among U.S. adults.

PURPOSE: This prospective cohort study examined the association between specific leisure-time activity and mortality risk. METHODS: Data are from 1999 to 2006 U.S. National Health and Nutrition Examination Surveys and included adults followed through December 31, 2015 (n = 17,938, representing 191,463,892 U.S. adults). Participants reported specific leisure-time activities performed at moderate-to-vigorous intensity. Walking, bicycling, running, dance, golf, stretching, and weightlifting were examined. Cox proportional hazards models (adjusted hazard ratios [aHRs]; 95% confidence intervals [CIs]) assessed the association of individual activities with the risk of all-cause mortality, CVD mortality, and cancer mortality. RESULTS: Over a median follow-up of 11.9 years, 3799 deaths occurred. Any leisure-time walking ([aHR], 0.73; 95% CI, 0.66-0.82), bicycling (aHR, 0.73, 95% CI, 0.59-0.91), and running (aHR, 0.70; 95% CI, 0.59-0.84) were associated with lower all-cause mortality compared with no participation in the specific activity. Dance, golf, stretching, and weightlifting were not associated with mortality. Comparable results were observed when activities were categorized as none, less than 60 min/wk, or 60 minutes or more/wk. Walking and running were similarly associated with the risk of CVD mortality. CONCLUSIONS: Participating in moderate-to-vigorous walking, bicycling, or running may be particularly beneficial for health and longevity.

Effects of phosphorus and calcium to phosphorus consumption ratio on mineral metabolism and cardiometabolic health.

Phosphorus is a common additive used in food processing that is typically consumed in excess of the recommended daily allowance; however, our knowledge of its effects on health, in the context of normal renal function, is limited. Unlike phosphorus, calcium intake is generally less than recommended, and it has been hypothesized that the calcium to phosphorus ratio may be partly responsible for the proposed negative health consequences. Therefore, this study sought to determine the effects of increased phosphorus additive intake, in the context of high calcium consumption, on endocrine markers of mineral metabolism and cardiometabolic health. An outpatient feeding study was performed in which healthy adults were fed a run-in control diet for 2 weeks followed by a phosphorus additive enhanced diet with supplemental calcium to an approximate ratio of 1 (experimental diet) for 2 weeks. Blood and urine samples were collected, and participants had brachial flow-mediated dilatation measured, with analyses comparing follow-up measures to baseline. Two weeks of experimental diet increased serum fibroblast growth factor 23 concentrations but lowered body weight and serum leptin; however, other phosphorus responsive factors such as osteopontin and osteocalcin did not increase. A complementary study in male mice also demonstrated that the regulation of known dietary phosphorus responsive factors was mostly abrogated when dietary calcium was raised in parallel with phosphorus. In conclusion, the study identifies weight, leptin and insulin as responsive to dietary phosphorus and that certain aspects of the systemic phosphorus response are attenuated by a corresponding high calcium intake.

The Association of Sport and Exercise Activities With Cardiovascular Disease Risk: The Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: This study assessed the independent associations between participation in self-reported sport and exercise activities and incident cardiovascular disease (CVD). METHODS: Data were from 13,204 participants in the Atherosclerosis Risk in Communities Study cohort (1987-2015). Baseline sport and exercise activities were assessed via the modified Baecke questionnaire. Incident CVD included coronary heart disease, heart failure, or stroke. Multivariable-adjusted Cox proportional hazard models assessed the association of participation in specific sport and exercise activities at enrollment with risk of CVD. RESULTS: During a median follow-up time of 25.2 years, 30% of the analytic sample (n = 3966) was diagnosed with incident CVD. In fully adjusted models, participation in racquet sports (hazard ratio [HR] 0.75; 95% confidence interval [CI], 0.61-0.93), aerobics (HR 0.75; 95% CI, 0.63-0.88), running (HR 0.68; 95% CI, 0.54-0.85), and walking (HR 0.89; 95% CI, 0.83-0.95) was significantly associated with a lower risk of CVD. There were no significant associations for bicycling, softball/baseball, gymnastics, swimming, basketball, calisthenics exercises, golfing with cart, golfing with walking, bowling, or weight training. CONCLUSIONS: Participation in specific sport and exercises may substantially reduce the risk for CVD.

Intrapersonal and Environmental Correlates of Bicycling in U.S. Adults.

INTRODUCTION: Bicycling is a health-promoting physical activity, but little is known about the factors that influence this behavior in the U.S. The objective of this cross-sectional study was to identify multilevel ecologic correlates of bicycling behaviors in a nationally representative sample of U.S. adults. METHODS: This analysis, conducted in 2016-2017, utilized data from the 2012 National Survey of Bicyclist and Pedestrian Attitudes and Behaviors (n=7,509; N=246,155,593). Weighted logistic regression models were utilized to examine the association between intrapersonal, perceived environment, and objective environment variables and total, recreation, and transportation bicycling. RESULTS: Significant differences were identified when bicyclists were compared with non-bicyclists. Respondents whose most recent ride was for recreation had significantly higher odds of being male, younger, white, and college educated, and significantly lower odds of being retired or a homemaker. Respondents who reported that their most recent ride was for transportation had significantly higher odds of being male, younger, and a student, and had significantly lower odds of being a high school graduate. Transportation riders also had significantly higher odds of perceived presence of a bike lane or path within one-quarter mile of their residence, and living in a more rural area. CONCLUSIONS: In the U.S., recreation bicycling is a choice-based behavior, whereas transportation bicycling may be more influenced by the perceived and objective built environment. Interventions should consider how to make recreation and transportation bicycling more accessible and affordable to all individuals.

Associations of Physical Activity, Sedentary Time, and Screen Time With Cardiovascular Fitness in United States Adolescents: Results From the NHANES National Youth Fitness Survey.

BACKGROUND: Most US adolescents do not meet guidelines of at least 60 daily minutes of moderate- to vigorous-intensity physical activity. In addition, sedentary behaviors among this age group are of increasing concern. This study examined the association of movement behaviors with cardiovascular fitness among US adolescents. METHODS: Data from the 2012 NHANES National Youth Fitness Survey were used to assess the association of movement behaviors (physical activity, sedentary time, screen time) with cardiovascular fitness among adolescent males and females. Multiple logistic regressions were used to test the independent and interactive effects of movement behaviors on cardiovascular fitness. RESULTS: Among females, physical activity was directly associated with cardiovascular fitness; no significant association was observed between sedentary behaviors and CVF. Among males, sedentary time moderated the relationship between physical activity and cardiovascular fitness, such that a significant, direct association was only observed among those with high sedentary time (OR: 5.01; 95% CI: 1.60, 15.70). CONCLUSIONS: Results from this cross-sectional analysis suggest that among female US adolescents, physical activity, but not sedentary behavior, is associated with cardiovascular fitness. Among males, the interaction between physical activity and sedentary time seems to be important for cardiovascular fitness. Longitudinal studies are warranted to confirm these findings.

Correlates of Helmet Use Among Recreation and Transportation Bicyclists.

INTRODUCTION: Helmet use prevents injury and mortality if a bicyclist is in a collision while riding. This cross-sectional study sought to identify domain-specific (recreation versus transportation) correlates of helmet use among U.S. adult bicyclists, using nationally representative data from 2012. METHODS: This analysis, conducted in 2015-2016, utilized data from the 2012 National Survey of Bicyclist and Pedestrian Attitudes and Behaviors, administered for the National Highway Traffic Safety Administration. Bivariate logistic regressions identified sociodemographic, behavioral, and environmental correlates of helmet use among U.S. adult bicyclists. Backwards elimination procedures selected final multivariate models for bicyclists' helmet use in both domains. RESULTS: Among recreation cyclists, helmet use was significantly associated with income ($30,000-$75,000, OR=1.79, 95% CI=1.04, 3.10; ≥$75,000, OR=2.34, 95% CI=1.38, 3.97), safety training (OR=2.94, 95% CI=1.46, 5.93), not riding at dark (OR=1.92, 95% CI=1.24, 2.98), feeling threatened while riding (OR=2.24, 95% CI=1.12, 4.45), and using bike lanes/paths (OR=2.04, 95% CI=1.42, 2.93). Helmet use among transportation riders was significantly associated with education (less than high school, OR=2.45, 95% CI=1.13, 5.32; post-high school, OR=3.55, 95% CI=1.96, 6.42), income ($30,000-$75,000, OR=2.11, 95% CI=1.17, 3.8; ≥$75,000, OR=2.33, 95% CI=1.26, 4.27), unemployment (OR=0.29, 95% CI=0.11, 0.76), not using electronics while riding (OR=2.3, 95% CI=1.41, 3.75), safety training (OR=3.19, 95% CI=1.44, 7.07), and injury while riding within the past 2 years (OR=2.81, 95% CI=1.14, 6.94). CONCLUSIONS: Correlates of helmet use among bicyclists are domain specific. Although confirmatory longitudinal studies are needed, findings suggest that interventions to increase bicyclists' helmet use consider riding domain.

The Association of Trip Distance With Walking To Reach Public Transit: Data from the California Household Travel Survey.

INTRODUCTION: Use of public transit is cited as a way to help individuals incorporate regular physical activity into their day. As a novel research topic, however, there is much we do not know. The aim of this analysis was to identify the correlation between distance to a transit stop and the probability it will be accessed by walking. We also sought to understand if this relation was moderated by trip, personal or household factors. METHODS: Data from the 2012 California Household Travel Survey was used for this cross-sectional analysis. 2,573 individuals were included, representing 6,949 transit trips. Generalized estimating equations modeled the probability of actively accessing public transit as a function of distance from origin to transit stop, and multiple trip, personal and household variables. Analyses were conducted in 2014 and 2015. RESULTS: For each mile increase in distance from the point of origin to the transit stop, the probability of active access decreased by 12%. With other factors held equal, at two miles from a transit stop there is a 50% chance someone will walk to a stop versus non-active means. The distance-walking relation was modified by month the trips were taken. CONCLUSIONS: Individuals appear to be willing to walk further to reach transit than existing guidelines indicate. This implies that for any given transit stop, the zone of potential riders who will walk to reach transit is relatively large. Future research should clarify who transit-related walkers are, and why some are more willing to walk longer distances to transit than others.

The Effect of Light Rail Transit on Physical Activity: Design and Methods of the Travel-Related Activity in Neighborhoods Study.

BACKGROUND: Use of mass transit has been proposed as a way to incorporate regular physical activity into daily life because transit use typically requires additional travel to access and depart the stop or station. If this additional travel is active, a small but potentially important amount of physical activity can be achieved daily. Although prior research has shown that transit use is associated with physical activity, important questions remain unanswered. Utilizing a major expansion of the Houston, TX, USA light-rail system as a natural experiment, the Houston Travel-Related Activity in Neighborhoods (TRAIN) Study was developed to address these unanswered questions. PURPOSE: The purpose of the TRAIN Study is to determine if the development of light-rail lines in Houston, TX, USA will prospectively affect both transit use and physical activity over 4 years. We also aim to understand how contextual effects (i.e., moderators or interaction effects), such as the neighborhood built environment and socioeconomic factors, affect the primary relations under study. METHODS: The TRAIN Study is a longitudinal cohort design, in which participants are recruited at baseline from a 3-mile buffer around each of the three new lines and measured annually four times. Recruitment is accomplished via telephone contact, ads in newspapers and advertising circulars, and targeted community outreach. Data are collected via mail and include questionnaire-assessed factors, such as perceived neighborhood characteristics, attitudes about transportation, demographics, and reported physical activity; a travel diary; and accelerometry. Additionally, field-based neighborhood audits are conducted to capture micro-scale environmental features. To assess macro-scale environmental characteristics, we utilize GIS mapping and spatial analyses. Statistical analyses will be conducted using latent growth curve modeling and discrete choice models, with a focus on identifying moderating factors (i.e., statistical interaction effects). Selection bias will be controlled via propensity score analysis. CONCLUSION: The TRAIN study is a unique opportunity to study how a multi-billion dollar investment in mass transit can simultaneously affect transportation needs and physical activity behavior. This comprehensive evaluation will provide needed evidence for policy makers, and can inform health impact assessments of future transportation projects around the world.